Chronic Kidney Management of Chronic Kidney …

1 Guidelines for Clinical Care Quality Department Ambulatory Chronic Kidney Disease Guideline Management of Chronic Kidney Disease Team Team Leader Patient population: Adults with Chronic Kidney disease (CKD). Jennifer Reilly Lukela, MD Objectives: General Medicine 1. Identify populations that may benefit from more systematic screening for CKD and provide an Team Members overview of methods for screening and diagnosis. R. Van Harrison, PhD. Medical Education 2. Outline treatment options for patients with CKD to decrease progression of renal deterioration and Masahito Jimbo, MD.

2 Potentially decrease morbidity and mortality. Family Medicine 3. Highlight common co-morbid conditions such as cardiovascular disease and diabetes, emphasizing Ahmad Mahallati, MD the importance of aggressive Management of these conditions to potentially decrease morbidity and Nephrology mortality among patients with CKD. Rajiv Saran, MBBS Key points Nephrology Annie Z. Sy, PharmD. Background Quality Management Despite increasing prevalence of CKD, it is often under-recognized and under-treated. [A]*. Program Evidence for screening and Management of early stage CKD is limited due to absence of large randomized controlled trials.

3 Initial Release: Definition and Staging (Tables 1 and 2). November, 2013 Kidney damage for > 3 months, defined by structural or functional abnormalities of the Kidney , with Interim/Minor Revision: or without decreased GFR. March, 2014. June, 2016 Diagnosis Screen patients with diabetes annually for microalbuminuria if not on an ACE inhibitor or ARB and for creatinine and estimated glomerular filtration rate [IA]. Consider screening for CKD among Ambulatory Clinical patients at increased risk, especially those with hypertension [IA] and patients aged > 55 years.

4 [IID]. Guidelines Oversight Grant Greenberg, MD, Laboratory studies needed to diagnose and stage CKD include an assessment of glomerular filtration MA, MHSA rate (GFR) (usually estimated by the MDRD equation) and urine studies for the presence or absence R. Van Harrison, PhD of albuminuria. [IC]. Ultrasound imaging for structural Kidney disease may also be helpful in certain populations. [IID]. Treatment Literature search service Taubman Health Sciences Blockade of the renin angiotensin aldosterone system with either an angiotensin converting enzyme Library inhibitor (ACEI) or an angiotensin receptor blocker (ARB) is the cornerstone of treatment to prevent or decrease the rate of progression to end stage renal disease.

5 [IA]. Blood pressure control (< 140/90) reduces renal disease progression and cardiovascular morbidity and mortality. Current evidence does not support stricter blood pressure control targets for the For more information: majority of patients with CKD [IA]. CKD patients with albuminuria may benefit from tighter 734-936-9771 control with a target of < 130/80 [IIA]. Optimally manage comorbid diabetes and address cardiovascular risk factors to decrease risk for cardiovascular disease the leading cause of mortality for patients with CKD. [IA] Statin or Regents of the statin/ezetimibe therapy is recommended in all CKD patients age 50 years to decrease the risk of University of Michigan cardiovascular or atherosclerotic events.

6 [IA]. Monitor for other common complications of CKD including: anemia, electrolyte abnormalities, abnormal fluid balance, mineral bone disease, and malnutrition. [ID]. These guidelines should not Avoid nephrotoxic medications to prevent worsening renal function. [ID]. be construed as including all Monitoring and Follow Up proper methods of care or excluding other acceptable The timing and frequency of CKD monitoring and follow up depends on disease severity and risk for methods of care reasonably directed to obtaining the same progression; GFR and albuminuria should be assessed a minimum of once per year.

7 [ID] (table 16). results. The ultimate Refer CKD stage G4 or G5 (see Table 2) to nephrology for co- Management and preparation for renal judgment regarding any specific clinical procedure or replacement therapy. Consider referral at earlier stage to assist with diagnosis of underlying cause treatment must be made by and/or treatment of common complications of CKD. [IC]. the physician in light of the circumstances presented by * Strength of recommendation: the patient. I= generally should be performed; II = may be reasonable to perform; III = generally should not be performed.

8 Levels of evidence for the most significant recommendations A = randomized controlled trials; B=controlled trials, no randomization; C=observational studies; D=opinion of expert panel 1 UMHS Chronic Kidney Disease Guideline, March 2014. Table 1. Definition of CKD Table 2. Staging of CKD. CKD is classified by the CGA system: Cause, GFR category, Albuminuria category Abnormalities of Kidney structure or function (defined by markers of Kidney injury or decreased GFR) present GFR GFR Terms for > 3 months with implications for health. (Either Categories (ml/min/.))

9 Criterion is sufficient for diagnosis.) m2). 1. Markers of Kidney damage (one or more): G1 > 90 Normal or high Albuminuria (AER 30mg/24hrs; ACR G2 60-89 Mildly decreased 30mg/g) G3a 45-59 Mildly to moderately Urine sediment abnormalities decreased Electrolyte and other abnormalities due to G3b 30-44 Moderately to severely tubular disorders decreased Abnormalities detected by histology G4 15-29 Severely decreased Structural abnormalities detected by imaging G5 < 15 Kidney failure History of prior Kidney transplantation Albuminuria AER ACR Terms 2. GFR < 60 mL/ Categories (mg/24hrs) (mg/g).

10 A1 < 30 < 30 Normal to * GFR = glomerular filtration rate; AER = albumin excretion rate; ACR = albumin-to-creatinine ratio mildly increased A2 30-300 30-300 Moderately Modified from KDOQI Clinical Practice Guidelines for the increased Evaluation and Management of Chronic Kidney Disease: A3 > 300 > 300 Severely (2013) increased AER = albumin excretion rate ACR = albumin-to-creatinine ratio Table 3. Common Risk Factors for the Table 4. Common Causes of Acute or Acute on Development of CKD Chronic Kidney Injury Diabetes Volume depletion Hypertension Acute urinary obstruction Age > 55 years Use of diuretics, ACE or ARB.